Medical Records should be documented with complete and accurate information of patients along with correct administered medications. Tampering or altering medical records is illegal and is a crime punishable with fines and jail time. By doing such, can mislead and can cause harm to patients. But if you are dealing with such accusations or complaints, it is best to seek help from a nurse attorney.

At the time of the initial incident, an RN was employed as a Staff Nurse at a hospital in Plano, Texas, and has been in this position for one (1) year and five (5) months.

On or about May 29, 2005, the RN failed to document her attempted communication with the physician and subsequent communication with the pharmacy regarding clarification of a physician’s order to administer “Vitamin 2.5 mg this am.” The RN’s conduct resulted in an incomplete medical record and was likely to injure the patient in that subsequent caregivers would not have accurate information on which to base their care decisions.

On or about August 24, 2005, the RN failed to administer K-dur to a patient, as ordered by the physician, after she noted the order at 1635. The medication was subsequently administered by another nurse on the next shift. The RN’s conduct was likely to injure the patient from non-efficacious care.

On or about September 5, 2005, the RN failed to note and implements a physician’s order to apply Thromboembolic Deterrent (TED) hose for the patient, written at 14:57 during her shift, as required. The RN’s conduct was likely to injure the patient from the possible formation of peripheral blood clots.

On or about September 16, 2005, the RN failed to note and implement a physician’s order to administer Solumedrol 125 mg intravenously to a patient, as required. The RN’s conduct was likely to injure the patient from non-efficacious care.

In response to the incidents, the RN states that she had called the physician to clarify the order but he had not called back before the pharmacy contacted her about the order. According to the RN, the pharmacy technician stated that the pharmacy would contact the physician and send both the medication and a corrected order once the order had been clarified. She also states that she noted the order and initiated the procurement process from the pharmacy but she is unsure of the time frame before the medication was profiled in the system and was delivered by the pharmacy. And added that the physician did not at any time insinuate the TED hose was an absolute necessity and that she placed the TED hose on the bedside table when they arrived at 17:00, asking the on-coming nurse for the next shift to apply them. Lastly, the RN states that the order was somehow missed, possibly because the chart may have been placed back into the carousel or the chart may have remained with the physician, so the order was not noted and was not sent to the pharmacy.

Therefore, as a result of the RN’s misconduct, the Board had to take disciplinary action against the RN. The sanction given to the RN was based on the evidence presented to the Board.

The RN should have consulted a nurse attorney for help and assistance when dealing with such kind of case. It is the better way to have your case solve and end it with a positive outcome.

Do you have questions about the Texas Board of Nursing disciplinary process? Contact The Law Office of Nurse Attorney Yong J. An for a confidential consultation by calling or texting 24/7 at (832) 428-5679 and ask for attorney Yong.